SEER Training Modules
Case #4
Click an information source below to view the case history.
Physical Exam
05/27/XX
48-year-old male with L upper quadrant pain for a month. Had abnormal CT, IVP, renal nuclear scan at outside facility.
X-Rays & Scans
05/19/XX
CXR normal.
05/20/XX
CT showed large L hydronephrosis and UP junction obstruction. No lymphadenopathy.
05/27/XX
Retrograde cystoscopy: anterior urethra WNL. Prostatic urethra showed mild BPH. Bladder negative. L retrograde ureteropyelogram revealed non-functioning L kidney with ureteropelvic junction obstruction, markedly dilated L pyelocaliceal system, longstanding hydronephrosis.
Operative Findings
05/28/XX
Extensive inflammation of left kidney parenchyma, kidney huge and grapefruit sized. No complications during procedure.
Pathological Reports
05/28/XX
L kidney nephrectomy: high grade papillary urothelial carcinoma of renal pelvis w/extension through muscularis propria into peripelvic adipose tissue. Ureter margin negative. Negative involvement of adrenal, renal vein and artery. No lymph nodes identified.
Treatment
05/28/XX
Surgery: Left nephroadrenalectomy.
07/11/XX
Radiation: Began beam radiation 3000 cGy treatment of renal bed.
07/28/XX
Chemotherapy: Began Chemo – Gemzar, carboplatin.
